Bottom line...he might want to think long and hard about gambling with his health based on these kinds of speculations. Nobody said "high LDL-P will do you in" but since so little is known about what these extreme values do mean, the prudent course is to bring them down.

I full understand the notion of "physiological insulin resistance" but once again, it is pure conjecture that this explains his FBG and he needs to monitor this. Ditto for the rest such as "You can have over 300 TC and over 200 LDL and still be protected from a coronary event by having sub 3.5x TC/HDL and 1.0x Trig/HDL ratios" not to mention that his TC is over 400 and his LDL over 300. You are completely distorting the notion of risk markers and, in any event, these markers were not developed with a population charaterize by extreme outliers such as this.

Then the elevation is more transitory than caused by FH. This is why you need to put his #s in the context of his overall experience, not just run to the latest flavor of the month cholesterol expert and believe that high LDL-P will do you in.

I didn't say he's fully protected from CVD. I said though that it's inflammation that will trigger an actual event. Yes, for there to be an event there has to be atherosclerosis, which I characterized as a long-term risk that eventually has to be dealt with. But he can buy some time by keeping his trigs low. As I said, he needs to see if this high level is a response to his dietary change or he's always had that, in which case his problem is familial. High LDL in the context of a dietary change and within the specific background of losing weight is less unusual.

1) An FBG of 101 is not a "non-issue" if it continues to rise. The advice given was to keep an eye on it to see where it goes from here. Your interpretation is just that- an interpretation and it is not the only possibility.
2) The HDL/Trig ratio is only a risk marker and the idea that with an LDL-C of 425 you are "protected" from CVD by virtue of this or other risk markers is pure conjecture. The reality is that such extremely high levels of LDL are so unusual that nobody really knows what it means at this point.

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Answers

In your case, an NMR test is really not going to tell you anything of use. The only really useful parameter in an NMR is LDL-P and with an LDL-C (I am assuming thats what is was) of 363, your LDL-P is very, very likely going to come back very high since you no doubt have a boatload of LDL particles. The NMR will probably show Pattern A since this is common with people on "Paelo" diets but that doesn't mean anything other than that a preponderance of the large number of particles are large. People with familial hypercholesterolemia also have mostly large LDL particles and they still get heart disease.

So, the reality is that you have very high LDL and the NMR is not going to change that. The only question for you is what does that mean and what are you going to do about it. You still may want to have a physician try to rule out familial hypercholesterolemia and assuming its not that and also assuming you have no symptoms of any kind, the only reasonable conclusion is that your LDL went way up because you changed your diet. That has happened to scores of people myself included and as I see it and based on my experience, here is what I suggest:

1) Stop listening to the many Internet voices who, for the most part, have no idea what they are talking about (except this one of course :)

2) You can also decide to forget about the whole issue but you should realize that nobody has the slightest idea what the future holds for Paleo eaters with high LDL over time. Do you really want to experiment on yourself in this manner?

2) You can wait for a while to see if the number comes down over time. I have no idea how long is reasonable to wait so that would be up to you.

3) You can combine waiting with some dietary changes. Some people just seem to be "hyper responders" to saturated fat so you can cut down somewhat on that. I have been using more olive oil for cooking, some lard at times (half monounsaturated fat), and cut back on butter, cream (I use half and half), and I don't drink fat bomb smoothies or "Bulletproof coffee" anymore. If you are VLC, then I would also suggest eating a reasonable amount of carbs. I started with bananas and potatoes but I do now eat a slice of good sourdough bread most days and not to mention fruit and some other carbs. I have pretty much lost my "carbaphobia" but I don't go overboard either.

4) You might want to get Chris Kresser's series on high cholesterol. Its pretty good and you will learn a lot although I am not sure about his supplement programs. It would also be good to work with a sympathetic physician. Good luck on that.

5) Also, if that is your fasting blood glucose, I would keep an eye on that as its getting up there. If it goes up from there, it would definitely be worth trying to understand why.

In any case, come back here with your NMR results and I will try to help. Oh yes I forgot to say that my LDL went as high as 330 but after about 18 months, it started coming down and about two months ago it was 189 and I suspect my LDL-P is even lower. That reduction occurred BEFORE I started changing my fat intake and about a year after I started adding carbs. I will be interested in seeing my next report. I can't really say if it was time or the added carbs that made the difference.

First, the FBG of 101 is a non-issue. You're low-carbing and your body's trying to preserve glucose. It's called physiological insulin resistance and is temporary as long as your low-carb. Discussed umpteen times in the paleosphere.

Second, your TC and LDL suggest familial hypercholesterolimia. However, you need to examine your past results and see if these numbers resulted from your dietary change. It's possible that you could be ApoE4 and react inordinately to saturated fat. In such a case, you could lay off saturated fat and go heavy on MUFA. So no butter but EVOO.

Now, more and more people are pooh-poohing the particle size argument that exempted the large, bouncy LDLs from causing atherosclerosis. I never bought the particle size argument in the first place. In fact, the Framingham study showed unequivocally that the large particles still went into to the artery walls and turned into plaques. And this point was made repeatedly by the study's main authors.

Having said that, what ultimately matters is your HDL and Trigs. Your TC / HDL ratio is the best contra indicator of cardiovascular health. Again, confirmed indisputably by the Framingham study. Sub 3.5x is the best biomarker of cardiovascular health. Then comes the Trigs/HDL ratio. Under 1.0x is good. Up to 2.0x is ok. Over that and you start to display some degree of insulin resistance. Over 3.0x, you definitely have insulin resistance and impaired glucose tolerance.

You can have over 300 TC and over 200 LDL and still be protected from a coronary event by having sub 3.5x TC/HDL and 1.0x Trigs/HDL ratios. The reason is an important one. It's because for you to have a coronary event, you need something that breaks the cap, a catalyst that unhinges a plaque piece. This happens in a thrombosis up to 80% of the time when people have coronaries. And guess when a cap event happens: when you have inflammation throughout your body as evidenced by high Trigs/HDL and TC/HDL ratios. If you don't have much inflammation, your high LDL and TC could over the long-term set the groundwork for extensive atherosclerosis. However, this is a long-term risk of CVD and the immediate risk of a coronary event requries inflammation. Your chances of having a heart attack or stroke are still low if you keep your inflammaiton in check: i.e., trigs under 70 and HDL over 70 (but notice here that HDL loses its potency over 90 or so --- it maxes out there so the ratio loses its predictive value when TC is so high).

This view actually sees atherosclerosis (which high LDL-P induces) as a long-term threat and part of the aging process. Even those Egyptian mummies had extensive atherosclerosis when they ate a supposedly ancestral diet free from processed carbohydrates. In other words, very few people are completely without any atherosclerosis. Of course, you'd like to minimize it if you can help it. But atherosclerosis with inflammation is a whole lot more dangerous thatn without.

I didn't say he's fully protected from CVD. I said though that it's inflammation that will trigger an actual event. Yes, for there to be an event there has to be atherosclerosis, which I characterized as a long-term risk that eventually has to be dealt with. But he can buy some time by keeping his trigs low. As I said, he needs to see if this high level is a response to his dietary change or he's always had that, in which case his problem is familial. High LDL in the context of a dietary change and within the specific background of losing weight is less unusual.

Then the elevation is more transitory than caused by FH. This is why you need to put his #s in the context of his overall experience, not just run to the latest flavor of the month cholesterol expert and believe that high LDL-P will do you in.

1) An FBG of 101 is not a "non-issue" if it continues to rise. The advice given was to keep an eye on it to see where it goes from here. Your interpretation is just that- an interpretation and it is not the only possibility.
2) The HDL/Trig ratio is only a risk marker and the idea that with an LDL-C of 425 you are "protected" from CVD by virtue of this or other risk markers is pure conjecture. The reality is that such extremely high levels of LDL are so unusual that nobody really knows what it means at this point.

Bottom line...he might want to think long and hard about gambling with his health based on these kinds of speculations. Nobody said "high LDL-P will do you in" but since so little is known about what these extreme values do mean, the prudent course is to bring them down.

I full understand the notion of "physiological insulin resistance" but once again, it is pure conjecture that this explains his FBG and he needs to monitor this. Ditto for the rest such as "You can have over 300 TC and over 200 LDL and still be protected from a coronary event by having sub 3.5x TC/HDL and 1.0x Trig/HDL ratios" not to mention that his TC is over 400 and his LDL over 300. You are completely distorting the notion of risk markers and, in any event, these markers were not developed with a population charaterize by extreme outliers such as this.

My suggestion: Check your thyroid health, proper thyroid hormone levels help govern LDL receptors and then are needed for LDL turnover. If you have poor thyroid hormone levels your LDLs may not be getting "used" well, ie the LDLs (even fluffy buoyant types) sit around in the blood waiting to be used far too long and the longer they float around the greater the chance they become oxidized. Maybe needing improved selenium and iodine supplementation in your diet. Selenium can be gotten from high-selenium foods like brazil nuts, but iodine is very difficult to get from food sources today for which you may need a supplement.

You may need to get your Vitamin K2 levels increased. High Vitamin D3 creates MGP proteins that require Vitamin K2 to activate. Those MGP proteins help "clean up" the calcification from oxidized LDLs.

One thing to consider about the large vs. small LDL size is that folks with familial hypercholesterolemia (FH) tend to have large LDL size, yet a 3x risk for heart disease, and so a case where large LDL size does not appear protective. FH folks also have a high number of LDL particles (LDL-P), which is gaining more acceptance as a CVD predictor.

I have numbers similar to yours. If the NMR test is consistent with the first test, I'd definitely try to determine the cause of your very high LDL, which is likely still a problem even if it is mostly the large, buoyant kind. It might be Familial Hypercholesterolemia. Does your family have a history of high cholesterol and heart disease?